Urologist Perspectives Affect Treatments for Prostate Cancer

Karen E. Hoffman, MD

A physician’s perspective, and the therapies he most often prescribes, can have a big influence on whether his patients with low-risk prostate cancer are treated or put on active surveillance, a study has found.

That’s why the cancer-treatment profiles of those who treat prostate cancer should be publicly reported, making their therapy trends clear to prospective patients and referring doctors, suggested Hoffman et al, the authors of the study that appeared in July in JAMA Internal Medicine.

Although untreated low-risk prostate cancer is unlikely to cause symptoms or affect survival, most men in the United States who have the condition choose treatment with prostatectomy or radiotherapy, and thus are exposed to treatment-related side effects such as urinary dysfunction, rectal bleeding, and impotence, according to the study authors. Observation is an alternative that is endorsed by numerous professional societies and, in comparison to treatment, has been shown to offer similar survival outcomes with fewer complications in older men with low-risk prostate cancer, they noted.

Their study investigated whether physician factors, including characteristics of the diagnosing urologist, affect choices between treatment and observation in this population of men.

The authors found that urologists who treat intermediate- or high-risk prostate cancer and who graduated less recently from medical school were less likely to manage low-risk disease with observation.

Patients with low-risk prostate cancer were more likely to undergo medical interventions, including prostatectomy or external-beam radiotherapy, if their urologist performed those procedures routinely for men with higher-risk disease, the authors found. In conducting the study, the investigators analyzed data from a group of men aged 66 years and older and diagnosed from 2006 through 2009 with low-risk prostate cancer.

The authors obtained patient and tumor characteristics from the National Cancer Institute’s Surveillance, Epidemiology, and End Results cancer registries. They got information about diagnosing urologists, consulting radiation oncologists, cancer-directed therapies, and comorbid medical conditions from linked Medicare claims. Physician characteristics came from the American Medical Association’s Physician Masterfile.

The study’s population included 12,068 men diagnosed with low-risk prostate cancer by 2145 urologists. Of those men, 80.1% received treatment and 19.9% were observed.

The case-adjusted rate of observation varied widely across urologists, ranging from 4.5% to 64.2% of patients. Case-adjusted rates of observation varied across consulting radiation oncologists from 2.2% to 46.8%.

“The variance in treatment selection attributable to physicians was at least double the variance attributable to measured patientlevel characteristics such as age, comorbidity, cT category, and PSA level,” the authors pointed out.

Men seen by urologists only were more likely to undergo observation (1703 of 3890 [43.8%]) than men seen by a radiation oncologist and a urologist (700 of 8178 [8.6%]) (P < .001), the authors found. Overall, they reported, 70.8% (1703 of 2403) of men who underwent observation saw only a urologist.

“We postulate that the diagnosing urologist plays an important role in treatment selection,” they wrote, “because he or she is the first to convey the diagnosis to the patient and discuss disease severity and management options.”

As a result, the authors recommended that “Public reporting of physicians’ cancer management profiles would enable primary care physicians and patients to make more informed decisions when selecting a physician to diagnose and manage prostate cancer.”

This would help control the kind of overtreatment that has raised concerns about screening for prostate cancer through the measurement of levels of prostate-specific antigen, the authors wrote.